Sỏi trong gan: Dịch tễ, chỉ định và kết quả phẫu thuật

Nghiên cứu Y học Y Học TP. Hồ Chí Minh * Tập 8 * Phụ bản của Số 1 * 2004 62 SỎI TRONG GAN: DỊCH TỄ, CHỈ ĐỊNH VÀ KẾT QUẢ PHẪU THUẬT Văn Tần*, Nguyễn Cao Cương*, Hoàng Danh Tấn* TÓM TẮT Đặt vấn đề: Sỏi trong gan thường gặp ở các nước châu Á, là một bệnh khó điều trị, có thể gây biến chứng và tử vong cao. Ở nước ta, nhiều nghiên cứu về sỏi trong gan đã được báo cáo, đặc biệt là ở miền Bắc. Mục tiêu và phương pháp: nghiên cứu hồi cứu tất cả các trường hợp bị sỏi trong gan đến điều trị tại bệnh viện Bình Dân từ đầu năm 1995 đến hết tháng 9/2002. Tất cả các bệnh án đều được phân tích để tìm những đặc điểm về: Dịch tễ, Chỉ định điều trị,, Phẫu thuật và kết quả. Kết quả: Có 989 trường hợp bị sỏi trong gan đến điều trị tại bệnh viện Bình Dân trong gần 8 năm (1995- 9/2002). Tỉ lệ nam/nữ: 0.55, tuổi trung bình ở nam: 41 và ở nữ: 50. 60% từ các tỉnh đến điều trị và đa số là người lao động chân tay. Viêm đường mật là lý do nhập viện của hầu hết trường hợp. Nhập viện trong bệnh cảnh cấp cứu: 30%, sốc nhiễm trùng đường mật: 2%. Tiền căn mổ sỏi mật ít nhất một lần: 27.5% Siêu âm cho thấy sỏi trong gan trái chiếm một tỉ lệ khá cao và phần lớn kèm thêm sỏi ống mật chủ. Sỏi ống mật chủ là lý do điều trị chính cho đa số trường hợp. Hầu hết các trường hợp được chỉ định phẫu thuật do sỏi gây tắc mật ngoài gan và nhiễm trùng. 67.36% trường hợp được mổ hở và 95% trường hợp dọc ĐM chính lấy sỏi. Các phẫu thuật lấy sỏi phối hợp như xẻ nhu mô gan (9.45%) và cắt gan (24%) đã được ứng dụng thường quy khi sỏi không thể lấy hết được qua xẻ ĐM chính. Xẻ gan, ngoài việc lấy sỏi còn nong chỗ hẹp, tạo hình chỗ dãn của đường mật trong gan. Cắt gan thực hiện đa số là gan trái, qua mặt cắt có thể lấy sỏi trong gan còn lại. Để phòng ngừa sỏi không lấy được hay tái phát có thể di chuyển làm nghẹt đường mật, nối mật-ruột (10%) hay tạo hình cơ vòng Oddi (5%) cũng đã được thực hiện ở những trường hợp có chỉ định. Ở những trường hợp này, túi mật được cắt bỏ. Kết quả cho thấy 50% sỏi trong gan được lấy sạch, đường mật thông suốt ngay từ lần mổ đầu. Biến chứng phẫu thuật là 20.3% (86/423) và tử vong phẫu thuật là 2.13% (9/423). Trong theo dõi, 26% các trường hợp phải nhập viện lại vì viêm đường mật, đa số do sỏi chưa lấy hết hay tái phát đã di chuyển, làm nghẹt mật và 2/3 trong số trên phải can thiệp phẫu thuật hở. Bàn luận và Kết luận: Sỏi trong gan còn là một bệnh phức tạp của chúng ta, ngay cả khi có những phương tiện điều trị hiện đại. Phòng ngừa không cho sỏi hình thành hay tái phát trong gan và điều trị trừ căn là những vấn đề mà chúng ta cần nghiên cứu. SUMMARY INTRAHEPATIC STONES (IHS): EPIDEMIOLOGY, SURGICAL INDICATIONS AND RESULTS Van Tan, Nguyen Cao Cuong, Hoang Danh Tan * Y Hoc TP. Ho Chi Minh * Vol. 8 * Supplement of No 1 * 2004: 412 - 419 ABSTRACT Background: IHS are a special pathology of the Asian countries. The etiologies and the mechanism of stone formation are not the same as in the extrahepatic stones (EHS). Deformation of the IHBD are often seen. Bile stasis and infections might be 2 predipose factors. The radical treatment is difficult and the prevention of the recurrence is still a challenge. Purpose: We study the IHS for the aims of researching: The patients characteristics, The Indications of Chuyên đề Hội nghị Khoa học Kỹ thuật BV. Bình Dân 2004 412 Y Học TP. Hồ Chí Minh * Tập 8 * Phụ bản của Số 1 * 2004 Nghiên cứu Y học treatment, The Surgical procedures and the Results. Material and Method: Retrospectively, we analyse the chart of the IHS patients treated at Binh Dan Hospital from 1995 to 2002. In this period, there are 989 cases of IHS admitted and treated in our hospital. Results: The male/female ratio is 1.83 and the middle age is 46 for the male and 48 for the female. 60% of the patients came from the provinces and almost were farmers. Majority of them admitted with a clinical picture of cholangitis that 30% in urgent state, 1.5% in septic shock, 20.32% having had at least one operation for biliary stones in their past history. Different preoperative complications (11.3%), such as liver abscesses, localized atrophic liver, acute pancreatitis, biliary peritonitis, septic shock, hemobilia are noted. On operation, we found 77% of patients that the stones are in the left liver. 64% has had associated EHS; 58.44%, multiple alternant dilatation-stenosis of the intrahepatic bile duct (IHBD); 7.88%, liver cirrhosis; 2.52%, biliary liver abscesses; 1.41%, round worm in the BD; 1.11%, BD carcinoma; 2%, other liver lesions. Majority of stones are brown pigment type. The surgical treatment is indicated in 61% of patients. Almost of the surgical procedures are removal of stones through a CBD incision (86.75%). Hepatotomies (4.5%), partial hepatectomies (16%) or a lithotripsy (12%) were applied to clear the stones in special and complicated cases. A biliary-intestinal anastomosis or a sphinteroplasty (7.2%) are also performed for preventing cholangitis due to CBD obstruction by emigrated stones. In 26.33% of choledochotomy is closed without drainage. As results of surgical treatment, in 51% of patients, the IHBD are free of stones and of stenosis. Complications and deads in surgical cases are 15.23% and 2.13%. In the middle and long term follow-up, 26% of patients readmitted by cholangitis due to residual or recurrent stones that 2/3 of them must be reoperated. Discussion and Conclusion: IHS are still a difficult disease to treat even with the advanced techniques. Radical treatment for clearing the IHS and for repairing the intrahepatic BD defect can prevent the recurrent stones and their consequences. IHS, a disease of BD system usually met in Viet Nam. Their incidence varied from 15% to 50% of the biliary stones according to the region(43,44). The etiology and the pathogenesis are unclear(1,2,3,4,5,6,7,8,9), but bile stasis and infections due to deformation of the IHBD might be 2 important factors. Almost stones found are brown pigment type. The radical treatment is difficult relating to clear the stones from the BD system, to detect the residual stones and to prevent their recurrence(20,21,22,23). There aren’t consent for therapeutic indications, conservative or invasive techniques(17,24,58). In the recent years, for the invasive techniques, minimally invasive surgery was applied and had a big improvement but conventional surgery is still needed(35,36,40,41,42 43, 44,45,46). PURPOSE: The study is aiming to find: - The epidemiology, the hepatobiliary lesions related to the stones and the clinical characteristics. - The therapeutic indications and the surgical treatment results. From these standpoints, we can recommand a standard treatment. MATERIALS AND METHOD It is a retrospective study of all patients having IHS treated at Binh Dan Hospital from 1995 to September 2002 in analysing the details illustrated in the charts of patients about the epidemiology, the clinical, the lab data, the hepatobiliary lesions, the therapeutic indications and the results. In this period, there are 989 patients of IHS in 14.835 patients having BD stones (15%) admitted and treated in our hospital. A choledochotomy is performed through a median supraumbilical laparotomy for BD exploration and for removing the stones. For controlling and clearing the residual stones, we use at first the finger then the instruments. If the stones can’t be removed, a C-arm Chuyên đề Hội nghị Khoa học Kỹ thuật BV. Bình Dân 2004 413 Nghiên cứu Y học Y Học TP. Hồ Chí Minh * Tập 8 * Phụ bản của Số 1 * 2004 cholangiography, an IOUS, a choledoscope with a lithotriptor probe can be used for pulverisating the big and incarcerated stones before removing them by dormia basket and by irrigating. An ERCP-ES, a hepatotomy, a hepatectomy or a hepato-hepatectomy are also needed in special cases. In the postoperative period, we remove the residual, the retained and the recurrent stones either by ERCP, through the T tube tunnel or percutaneously through a new fistulae toward the dilatated BD by a puncture needle with progressive dilatation directed by an IOUS. RESULTS There are 35.5% male and 64.5% female that the middle age is 46 for male and 48 for female. Majority of them are sea fishmen and farmers that 40% living in Ho chi minh city, 60% in the South and the Center of Viet Nam. 90% of patients have had episodic epigastric pain or even acute cholangitis (30%) and septic shock (1.5%). A prehistory of biliary surgery were found in 198 cases (21%) that 62 at other hospital and 136 at Binh Dan hospital. There are only 1/3 of patients having pure IHS. Association of EHS is frequent. Pure IHS: 36.6%, IHS + EHS: 63.4% A half of IHS found in the left liver Table 1 Sites of IHS/US % Right IHS 18% Left IHS 50% Bilateral IHS 32% Multiple intrahepatic bile duct (IHBD) and liver lesions are observed Table 2 IHBD-Liver disorders Rate Cases IHBD dilatation+stenosis 66% 653 (fig 4) IHBD dilatation 9% 89 (fig 5) Liver abscesses 3% 30 (fig 6) Liver cirrhosis 10% 98 (HBsAg(+)11%) Segmental liver cirrhosis 2% 15 (fig 7) The other BD and liver lesions are also found in 55 patients (5.6%) Table 3 Other lesions of BD and liver Cases BD cancer 5 GB cancer 1 HCC 5 Liver hemangioma 8 Acute hepatitis 2 IHBD cysts (fig 8) 3 Macrocopic liver cirrhosis 22 BD round worm 9 The complications related to BD stones on admission are found in 106 patients (11.3%) Table 4a Complications Cases % Liver abscesses 30 3 Acute pancreatitis 15 1.5 Necrotizing, hemorrhagic pancreatitis 3 Chronic pancreatitis 3 Septic schock 20 2 Bile peritonitis, necrotic GB 7 1 Obstruction of BD 22 2.3 Stenosis of biliary-digestive stoma 3 Hemobilia 3 A bile culture for 55 cases, there are 59 bacteries found. All of them are sensible to 3rd generation cephalosporine and aminoglycoside. Table 4b Bacteries N ATB Sensibilities E Coli 20 Cepha 3, Aminosides Enterobacter 12 same Proteus 11 same Klebsiella 3 same Pseudomonas 2 Aminosides, Quinolone Strept A hemolyis 1 Cepha 3 Other concommitent diseases found in 36 cases (3.5%). Table 5 Associated diseases Cases Gastroduodenal ulcer or gastritis 16 Diabetes mellitus 6 Hyperthyroid and Grave’s diseases 3 Duodenal diverticula 2 Chuyên đề Hội nghị Khoa học Kỹ thuật BV. Bình Dân 2004 414 Y Học TP. Hồ Chí Minh * Tập 8 * Phụ bản của Số 1 * 2004 Nghiên cứu Y học Associated diseases Cases Colon carcinoma 2 Splenomegaly 1 Heart diseases 6 According to the distribution, the number, the size, the nature of stones and the lesions of the BD and the liver, we have different therapeutic procedures either single or associated Table 6 Therapeutic procedures Cases % Conservative treatment: (small stones, asymptomatic, very high risk non emergency patients) 267 27 ERCP for removing EHS and IHS 59 6 Laparotomy for removing biliary stones by different procedures 663 67 In 663 cases of invasive procedures (conventional surgery), choledochotomy in 94%, hepatectomy 22%, hepatotomy 8.5% Table 7 Procedures Cases Rate Choledochotomy 623 94 Hepatotomy 43 8.5 Hepatectomy 146 22 (Hepato- hepatectomy) 26 4 Biliodigestive anastomosis 90 10 Sphincteroplasty 44 5 Cholecystectomy 107 17 Surgical results: After the 1st operation, the retained and residual IHS is 49.6% that 28% due to biliary decompression in emergency, 19% due to deep location and small size stones, especially in the right liver, 3%, really residual stones. Except the asymptomatic small stones, the majority of the remaining cases underwent a radical cure within a month. There are 19% of postoperative complications in which wound infections, bile fistula and post ERCP- ES cholangitis are usually met. For the other complications as liver failure, respiration problems, coagulation defect, renal failure, intraabdominal infections are found in emergency cases (126/663). Table 8 Complications Cases % - Wound infection 39 6 - Bile fistula 25 4 - Post ERCP-ES Cholangitis 16 2.4 - Liver failure 12 1.8 - Respiratory problems 9 - Coagulation disorder 8 - Renal failure 8 - Peritonitis, residual abscesses 6 - Incisional dehiscence and hernia 3 All the bacteries found in the infected wound are similar to the bacteries of the bile culture and sensible to the same antibiotics. 17 cases (1.72%) died in hospital, almost in the group of patients having complications before operations or having one or more concommittant diseases that 3 (0.92%) in the group of conservative treatment, 14 (2.1%) in the group of invasive treatment: 13 conventional surgery for the recurrent cases, 1 ERCP-ES. The causes of death. Table 9 Death causes Cases - Septic shock 9 - Liver failure 5 - Respiratory failure 2 - Cerebral vascular accident 1 Almost of the patients are followed up from 1 to 5 years. The middle and long term results are: recurrent stones with cholangitis, readmitted after the 1st radical cure in 26% (257 cases) and 17.5% (172/ 257 cases) must be reoperated at least 1 time since 1995, 8.3% (84/257 cases) conservative treatment (no surgical indications or not consent to operate). DISCUSSION IHS are usually found in Viet Nam, that appear mostly as brown pigment stones (calcium bilirubinate) but contain more cholesterol in composition, like in japanese study(5,15). In Viet Nam, the incidence of IHS varied from region to region. A statistic study from 1955 to 1999 on 4862 patients bearing biliary stones admitted at Binh Dan Hospital, Chuyên đề Hội nghị Khoa học Kỹ thuật BV. Bình Dân 2004 415 Nghiên cứu Y học Y Học TP. Hồ Chí Minh * Tập 8 * Phụ bản của Số 1 * 2004 South of Viet Nam, the incidence of IHS is 13%(44) with 4.5% pure IHS and 8.5.% associated IHS and EHS. Another study of Viet-Duc Hospital, North of Viet Nam in the period from 1976 to 1996 with 5390 patients having biliary stones, that incidence is 55%: pure IHS: 10%, IHS+EHS: 45%(43). The rate male/female is 0.55; that rate is higher than the rate of biliary stones in general (0.25). Male middle age is younger than female: 46/48. The clinical and pathologic characteristics, 21% had a history of biliary operation at least one time, so the IHS recur frequently. The rate of associated IHS and EHS is 63.4%, that is very high. No body knows the IHS or the EHS is primary stone. The IHS are found mostly in the left liver: Left liver stones (50%) > bilateral stones (32%) > Right liver stones (18%). There are 66% of associated dilatation and stenosis of IHBD. That rate is higher than the other studies in the foreign countries(20,21,22,23,24). It is the main cause of high recurrence of our IHS. The preoperative complications are high (10.6%), especially due to bile stasis and infection that the aerobic(11,44) and anaerobic bacteries(12), even the H. pylori are found(13,14); that rate is higher than the other studies in the foreign countries(17,19), it’s possible that patients coming to hospital lately. They relate closely to the postoperative complications and mortality rate: 19% and 1.72%. The concommittent hepatobiliary disorders is 5.6%, that may be the cause-effect of biliary stones. The main liver lesions are abscesses, liver atrophy and chronic hepatitis. In long standing IHS patients, some cases have had cholangiocarcinoma, especially for the patients which have brown pigment stone(56). The incidence of viral hepatitis (HBsAg + in 11%) is the same as in the normal population of our country. In the results of surgical treatment, there is high rate of retained and residual stones (50%) and complications (19%) after the 1st operations. For reducing this rate, the patients must be operated soon before having complications and the advanced techniques must be applied as cholangiography, IOUS, intra-operative endoscopic lithotripsy, dilatation-stenting of BD and ERCP for detecting and clearing the IHS then repairing the IHBD defects. The rate of reccurrent stones in our study in middle and long term follow up is 26% for the elective cases, like in other studies (30%). With advanced techniques as endoscopy(25,26,27), percutaneous endoscopic lithotripsy(28,29,30,31,32), associated extra and intrahepatic lithotripsy(33,34,35,36) or a cutaneous hepaticojejunostomy(37,38,39,40,41,42) with one or two subcutaneous loop, opened in the subcostal area for removing the retained, residual and recurrent stones, the rate of radical cure may increase. A hepatectomy, a hepatotomy or a hepato-hepatectomy are performed in cases of stones can’t be cleared by any of the above procedures, especially when the lesions of the BD and liver area dvanced and localized(43,44,45,46,47,48,49,50,57,58). For the associated disorders of the IHBD as cystic, neoplatic, a radical hepatectomy must be carried out(53,54), For IHBD cholangiocarcinoma, even a large hepatectomy is applied, the long term outcome depends on the localized or the diffuse lesions(55,56,57). Though many techniques are used, the residual and recurrent stones after operations in our study are still high (9% and 26%). The biliary tract and the liver are more and more damaged until hepatic failure either by stones and infections or by repeated invasive techniques. The succeding operations are more and more difficults and more and more complicated(51,52). For recommandations, we propose an allogorith of therapeutic indications: 1- For the cases of pure IHS, especially, asymptomatic small stones (<5 mm), they might be followed. 2- For the remaining cases, invasive treatment either conventional surgery or minimally invasive techniques is needed to clear the IHS and to repair Chuyên đề Hội nghị Khoa học Kỹ thuật BV. Bình Dân 2004 416 Y Học TP. Hồ Chí Minh * Tập 8 * Phụ bản của Số 1 * 2004 Nghiên cứu Y học the BD (completely patent) for preventing their recurrence. For clearing the stones from the BD, according to patient conditions, to the site, the nature and the complicated stones, to the state of liver and to the present equipment, many modalities might be applied either single or associated. The IHS can be cleared by choledochotomy, by endoscopic lithotrisy by hepatotomy or even by hepatectomy. For preventing their recurrence and the bile stasis and infection, all the BD stones must be cleared and all the abnormal BD must be repaired (plasty or dilatation-stenting) how to keep the BD system always patent. For treating the retained, the residual and the recurrent stones, we can remove them through: - a T tube tract with or without dilatation, - a new tract of a needle puncture toward the BD dilatation and stones with progressive dilatation directed by an imaging technique. - one or two stoma of cutaneous hepaticojejunostomy (adapted from the Hong Kong authors with or without modification as proposing by Chinese or India authors) or - an ERCP-ES with or without dilatation of the main BD. CONCLUSION IHS, a special diseases of the Asian countries, is difficult to treat. For the big or multiple stones with displacement of the BD system. there are often early and severe complications if the treatment is delayed. 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